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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# <br /> I SERVICE REQUEST# <br /> SCA,(\ <br /> OWNER/OPERATOR ^ <br /> S k yv\cc (\ � � `{ )GU CHECK if BILLING ADl7� <br /> FAcILry NA _ <br /> D 01 <br /> StiE ADDRESS <br /> 11DireS �Ck'v <br /> Street Number eNon strut me <br /> HONE Or MAWNGADD.REQS "`Dlfferem from Site Address) city <br /> Zi code <br /> z5 _ ker\y.5 5 4� C-1 <br /> CITY - - Street Number Stree me <br /> SC T� zip <br /> PHONE#1 ///��� T- APN# l�� <br /> (2,N ) r e� �_ T �� LAND USE APPLICATION# <br /> PHONE I#2 tJ L L EU. <br /> (L1Dh 0-3 BOS DISTRICT LOCATION CODE <br /> I CONTRACTOR/ SERVICE REQUESTOR <br /> [HOME <br /> EQUESTOR <br /> S1 t C <br /> 1 Q` 10Y1 �/ CHECK If BILLING ADDRESS�Ii Ji <br /> SINESS NAME PHONE# IJ <br /> �r I)7g#NG ADDRESS FAX# <br /> m• ( 1 <br /> C G STA ZIP <br /> E _ <br /> BILLING ACKN WLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project spec ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: S} K'\ YaV'%a \ � S- I -7 DATE:) o ^� - <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER M OTHER AnrHORYI AGENT[3 <br /> IfAPPLICANT is not the BILLAG PAR7T Proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYMEN <br /> RECEIVED <br /> OCT 2 0 1011 <br /> SAN JOAQUIN COUNTY <br /> HFALH DEPARTMENT <br /> ACCEPTED BY: ` l. . EMPLOYEE///���I V DATE. "l <br /> ASSIGNED TO: I �J � EMPLOYEE#: <br /> DATE: () <br /> Date Service Completed (it <br /> already completed): V <br /> SERVICE CODE: p/E: <br /> Fee Amount: 1152, — Amount Paid 15� Payment Date <br /> Payrrlen}7ype� - i-- Invoice# Check CJ , C /Received By:7 <br /> Cq► <br /> EHD 48-02-025 �' <br /> REVISED 11117/2013 SR FORM(Golden Rod) " <br />